HomeMy WebLinkAboutApp, License & Certifications The Commonwealth of Massachusetts Fee
Town of Yarmouth $150.00
Food Establishment License
Number: BOHF-15-1159-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
POOJANEN INC. 1011 ROUTE 28
A TO Z CONVENIENCE STORE SOUTH YARMOUTH, MA 02664
1011 ROUTE 28
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2022 LICENSE
TO OPERATE:
Retail
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2021 unless sooner suspended or revoked and is not
transferable.
Conditions
RETAIL FOOD SERVICE LESS THAN 25,000 SQUARE FEET
Board Hillard Boskey, M.D., Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Jr
Bruce G. Mur, , M' ', R.S., CHO
Hea th Director
The Commonwealth of Massachusetts Fee
Town of Yarmouth $110.00
Tobacco Product Sales License
Number: BOHTP-15-1161-07 Issue Date: 1/1/2022
Mailing Address: Location Address:
POOJANEN INC. 1011 ROUTE 28
A TO Z CONVENIENCE STORE SOUTH YARMOUTH, MA 02664
1011 ROUTE 28
SOUTH YARMOUTH, MA 02664
IS HEREBY GRANTED A 2022 LICENSE
This license is granted in conformity with the statutes and ordinances relating thereto,
and expires December 31, 2022 unless sooner suspended or revoked and is not
transferable.
Board Hillard Boskey, M.D.,Chairman
Mary Craig, Vice Chairman
of Charles T. Holway, Clerk
Debra Bruinooge
Health Eric Weston
Bruce G. Mum ;, MP , R.S., CHO
Health Director
TOWN OF YARMOUTH BOARD OF HEALTH
APPLICATION FOR LICENSE/PERMIT - 2022
* Please complete form and attach all necessarydocuments byDecember 18, 2021.
P
Failure to do so will result in the return of your application packet.
ESTABLISHMENT NAME:ftd Grt Lilaaef JIToI Cn114i.:Ce7 err-TAX ID:
LOCATION ADDRESS: 0 (I !gawk 11/cce 1,_WirwtMj TEL.#:SOK Gi f q 33.4
MAILING ADDRESS:
E-MAIL ADDRESS: tActeir€ShJct/ 1q- 1 ).7 --
OWNER NAME: niLs/a .L.- i‘ctsief
CORPORATION NAME (IF APPLICABLE): /,ganc . p,
MANAGER'S NAME:, ,�1 /'¢J`. p�� TEL.#: 3414• '
2 f 9(a3 -
MAILING ADDRESS: CoVi—cinv..t � < �� ,tl�Ylj2 l MA - 6244-3
POOL CERTIFICATIONS:
The pool supervisor must be certified as a Pool Operator,as required by State law. Please list the designated
Pool Operator(s) and attach a copy of the certification to this form.
1. 2.
Pool operators must list a minimum of two employees currently certified in standard First Aid and Community
Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the
employees below and attach copies of their certifications to this form. The Health Department will not use past
years' records. You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
FOOD PROTECTION MANAGERS - CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who is certified as a Food
Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000.
Please attach copies of certification to this application. The Health Department wil ords.
You must provide new copies and maintain a file at your establishment. `=
1. 2.
r��° 1 0 2 2021
PERSON IN CHARGE: HEALTH DEP
Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation.
1. 2.
ALLERGEN CERTIFICATIONS:
All food service establishments are required to have at least one full-time employee who has Allergen certification,
as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach
copies of certification to this application. The Health Department will not use past years' records. You must
provide new copies and maintain a file at your establishment.
1. 2.
HEIMLICH CERTIFICATIONS:
All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich
Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and
attach copies of employee certifications to this form. The Health Department will not use past years' records.
You must provide new copies and maintain a file at your place of business.
1. 2.
3. 4.
RESTAURANT SEATING: TOTAL#
ADMINISTRATION
Under Chapter 152,Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal
of any license or permit to operate a business if a person or company does not have a Certificate of Worker's
Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE
AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR
CERT. OF INSURANCE ATTACHED _
OR
WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED
Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK
APPROPRIATELY IF PAID: t /
YES V NO
MOTELS AND OTHER LODGING ESTABLISHMENTS
TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use,Transient occupancy shall be limited to
the temporary and short term occupancy,ordinarily and customarily associated with motel and hotel use. Transient occupants
must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall
generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days
within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient.
Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as
amended, shall generally be considered Transient.
POOLS
POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the
Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to
opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened.
POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State
certified lab, and submitted to the Health Department three(3)days prior to opening, and quarterly thereafter.
POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7)days of closing.
FOOD SERVICE
SEASONAL FOOD SERVICE OPENING:
All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health
Department to schedule the inspection three(3)days prior to opening.
CATERING POLICY:
Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required
Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health
Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Forms.
FROZEN DESSERTS:
Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to
the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the
above terms have been met.
OUTSIDE CAFES:
Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health.
OUTDOOR COOKING:
Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited.
TOBACCO PRODUCT PERMIT CAP
A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's
permit expiration date is considered an expired license, and the tobacco license cap is reduced.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
ti
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— =�- 1 Congress Street, Suite 100
6-1
( lit�i� �' Boston, MA 02114-2017
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www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: dOQ fenZ
.��-LCC ,��,�1� /4-7(7) LG nY6!r 612[x'
Address: /0 (( 4601t.
c?(
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City/State/Zip: guilt_ yei,,,e-K . (/�� //�C 1
Phone #: 5k- 6(
Are you an employer? Check the appropriate box: Business Type(required):
1.e l am a employer with employees (full and/ 5. 'etail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]**
4.ElWe are a non-profit organization, staffed by volunteers, 11.0 Health Care
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves.but the corporation has other employees.a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: �, 0 _, • a ,L , . -, f 'IA, If ; 10w1 i L. d 1 IC
Insurer's Address: 9 e ygnndt 9h. Racteci , ! 'jciny 'r, 1,441- 6-266
City/State/Zip: 9a rri,. Q& Q`ele t �G e
Policy # or Self-ins. Lic. # O YV G�C� Q (Z a
Expiration Date: (2-1
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct.
Signature: <1 .. 1e/ Date:
Phone#: T4'14 61-- cl [ 0 3
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
NOTICE , NOTICE
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EMPLOYEES a MMEMPLOYEES
y�o
91 540
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice
that I(we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
NorGUARD Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box AH, 39 Public Square, Wilkes-Barre, PA 18703-0020
ADDRESS OF INSURANCE COMPANY
POWC222912 02/12/2021 02/12/2022
POLICY NUMBER 973 Iyannough Road P.O. Box 1990 EFFECTIVE DATES
DOWLING &O'NEIL INSURANCE P Hyannis, MA 02601 508-775-1620
NAME OF INSURANCE AGENT ADDRESS PHONE#
Poojanen, Inc. 1011 Route 28 South Yarmouth, MA 02664
0
EMPLOYER ADDRESS
01/08/2021
8
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
0
0
m MEDICAL TREATMENT .
rn
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the ser-
vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER